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Cryptorchidism--(Undescended testis)
1.CHILD WITH AN EMPTY SCROTUM A PROBLEM-ORIENTED APPROACH
2. CHILD WITH AN EMPTY SCROTUM A PROBLEM ORIENTED APPROACH Dr.B.SELVARAJ MS;Mch; FICS; NEONATAL & PEDIATRIC SURGEON MELAKA MANIPAL MEDICAL COLLEGE MELAKA– 75150 MALAYSIA M M M C
3. CHILD WITH AN EMPTY SCROTUM Recognise various conditions Clinch correct diagnosis Appropriate investigations Timely surgical referral M M M C A PROBLEM ORIENTED APPROACH OBJECTIVES
4. CHILD WITH AN EMPTY SCROTUM UNDESCENDED TESTIS ECTOPIC TESTIS RETRACTILE TESTIS POST-TORSION ATROPHY M M M C CAUSES
5. Embryology Of Testicular Descend Primitive gonad in urogenital ridge turns into testis by a gene in the short arm of Y chromosome; Early Testis3 hormones testosterone from Leydig cells CSL regression Mullerian inhibiting substance from Sertolli cells Mullerian duct regression Insulin- like3 hormone Thickening of caudal gubernaculum holds testis close to inguinal abdominal wall Relative descend of testis M M M C 8 to 15 Wks of Gestation- Transabdominal Phase
6. Embryology Of Testicular Descend 28 to 35 Wks of Gestation- Inguinoscrotal Phase At 25 Wks Processus vaginalis elongates into gubernaculum Distal end of gubernaculum elongates and reach scrotum between 30- 35 wks Then testis descends through patent processus vaginalis Testosterone GFN CGRP Migration of gubernaculum along with testis to scrotum M M M C
7. Various Stages Of Testicular Descend M M M C
8. Classification Of Cryptorchidism (Hidden Testis) M M M C
9. UNDESCENDED TESTIS ETIOLOGY Anatomical Endocrine Iatrogenic • Short spermatic artery •Retroperitoneal Adhesion •Malfunctioning Gubernaculum •Narrow inguinal ring/ canal • Pituitary deficiency •Testosterone deficiency •Post Herniotomy M M M C
10. UNDESCENDED TESTIS Testicular descent is arrested in its normal path Rt side60%; Lt side30%; Bilateral10% Premies30%; Full term Neonates 4to5%; 3Month infant1to2%; 1Yr olds0.3% Empty poorly developed Scrotum M M M C
11. UNDESCENDED TESTIS Always associated with patent processus vaginalis Inguinal Hernia If the testis is palpable in groin do Milking Manuver to R/O Retractile testis Palpate perineum upper thigh to R/O Ectopic Testis If the testis is impalpable needs further workup to localize the testis M M M C
12. UNDESCENDED TESTIS M M M C
13. UNDESCENDED TESTIS Milking Manuver M M M C
14. UNDESCENDED TESTIS Complications M M M C TRAUMA TORSION TESTICULAR MALIGNANCY PSYCHOLOGICAL PROBLEMS INFERTILITY
15. UNDESCENDED TESTIS Postnatal Germ Cell Development M M M C
16. UNDESCENDED TESTIS Infertility Cancer Scrotum 4*c than core body temperature Ideal for spermatogenesis Transformation of Neonatal gonocyte to type A Spermatogonium is impaired This transformation occurs at 3to 6 months of age Dysplastic gonocyte is the cause for malignant transformation in early adulthood for infertility M M M C
17. UNDESCENDED TESTIS Workup In Bilateral Impalpable Testis: HCG stimulation test to confirm the presence of testis To localize testis the Gold standard is Laparoscopy Diagnostic Therapeutic USG of Groin Abdomen CT Scan Groin Abdomen MRI of Abdomen M M M C
18. UNDESCENDED TESTIS Management M M M C
19. UNDESCENDED TESTIS INGUINAL ORCHIDOPEXY M M M C
20. UNDESCENDED TESTIS INGUINAL ORCHIDOPEXY M M M C
21. Algorithm for Impalpable Testis M M M C
22. UNDESCENDED TESTIS DIAGNOSTIC LAPAROSCOPY Vas and Testicular vessels entering the internal inguinal ring Canalicular UDT Blind ending Vas and Testicular vessels Anorchia (Vanishing Testis) M M M C
23. UNDESCENDED TESTIS Laparoscopic Fowler Stephens M M M C
24. UNDESCENDED TESTIS Laparoscopic Fowler Stephens M M M C Prentiss Maneuver
25. UNDESCENDED TESTIS Complications of Orchidopexy Damage to Testicular vessels Testicular Atrophy Damage to Vas Deferens Infertility Retraction of Testis out of Scrotum Hemorrhage Wound infection M M M C
26. ECTOPIC TESTIS Testis after coming out of the external inguinal ring has migrated into an abnormal location Sites of the ectopic testis are - Superficial inguinal pouch - Perineum - Pre penile - Opposite side scrotum- crossed ectopic - Femoral triangle Diagnosis is obvious Orchidopexy is easy M M M C
27. Sites of UDT Ectopic Testis M M M C
28. ECTOPIC TESTIS- Perineal M M M C
29. RETRACTILE TESTIS Testis can be manipulated into the scrotum Testis is pulled and held high by overactive cremaster muscle Descends into scrotum whenever the child is relaxed/ sleeping By puberty testis grows in size and remain in the scrotum No intervention is needed M M M C
30. CHILD WITH AN EMPTY SCROTUM www.themegaller y.com
31. CHILD WITH AN EMPTY SCROTUM www.themegaller y.com
32. TAKE HOME MESSAGE Child should be operated on between 6months to 1year Undue delay in surgery carries the risk of infertility and malignancy in adult life Hormone therapy may be tried between 3to 6 months Retractile testis should not be operated Intra abdominal testis is best managed with Laparoscopy M M M C
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